Case Presentation

A 7 Years Old Boy with Closed Fracture of Supracondyler Humeri Sinistra Gartland III with Medianus Nerve Deficit

Arrange by: Pramadya Vardhani Mustafiza G0007129

Tutor: Dr. Tangkas Sibarani, SpOT, FICS

Orthopaedic and Traumatology Department of Sebelas Maret University Moewardi Hospital / Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta 2012

LEGALLY SHEET Case presentation with title A 7 years Old Boy with Closed Fracture of Supracondylar Humeri Sinistra with Medianus Nerve Deficit is arranged to fulfil the requirement in Orthopaedic and Traumatology Department Sebelas Maret University, Moewardi Hospital/Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta by: Pramadya Vardhani Mustafiza G0007129

Has been approved by Tutor of Orthopaedic and Traumatology Department in Prof. Dr. R. Soeharso Orthopaedic Hospital Surakarta. Surakarta, 9th February 2012 Tutor

Dr. Tangkas Sibarani, SpOT, FICS

CASE PRESENTATION

A. HISTORY 1. Patient Identity Name Sex Age Address Number of MR Date of Admission : IN : male : 7 y.o. : Kadipaten, Selogiri : 21 28 11 : 6th February 2012

Date of Examination : 6th February 2012

2. Chief Complain Pain on Upper Left Arm

3. History of Present Illness Auto-Allo Anamnesa Four hours before admission, patient fell when he tried to act as a Spiderman. He crawled his hands and knees on the floor. Suddenly, he fell with pronation positions and his left arm rotated externally. After that accident, patient could not move his arm because it was very painfull. His parents brought him to PKU Wonogori Hospital. He got X-Ray photos there. Because of limited facilities, he has reffered to Prof. Dr. R Soeharso Orthopaedic Hospital.

4. History of Past Illness History of Trauma : was denied

History of Hospitalized : was denied History of Allergy : was denied

B. PHYSICAL EXAMINATION 1. Primary Survey Airway Free, C-Spine Stable Breathing Spontaneous breathing, thoracoabdominal, 24 rpm Circulation BP: 117/73 mmHg, HR: 105 bpm Disability GCS E4V5M6, no lateralitation Exposure Axillary body temperature : 370C

2. Secondary Survey a. Head b. Eye : mesocephal, black hair : pale conjunctiva (-/-), both pupils were isochor (3mm/3mm), light reflex (+/+) c. Ear d. Mouth e. Nose f. Neck g. Chest h. Cor Inspection Palpation Percussion : ictus cordis was not seen : ictus cordis was not palpable : cardiac border was not widened : normal : normal : normal : normal : normal

Auscultation : heart rate 106 bpm, the intensity of 1st and 2nd was normal, there was no murmur i. Pulmo Inspection : chest expansion was equal between left and right side

Palpation Percussion

: tactile fremitus was equal between left and right side : sonor in both of lung

Auscultation : vesicular sound (+/+), no additional sound of lung j. Abdomen Inspection : equal surface of abdomen and chest

Auscultation : normal bowel sounds Percussion Palpation : tympani : pressure pain (-), liver and spleen were not palpated

k. Extremity : (also see Local status) Oedema + Cold Acral -

Motoric +5 +5 x +5

Sensoric -

3. Local Status Left Brachii Region a. Look There was sweling, deformity S-shape, hematom, and Pucker sign. b. Feel There was touch pain, fracture side temperature was warm, and neurovascular deficit (+) OK sign (-) c. Move ROM of elbow was limited because of pain C. 1st ASSESMENT Closed fracture of Left Humerus with Median Nerve Deficit

D. 1st PLANNING 1. X-Ray of Elbow (AP/Lat) 2. Laboratory Examination

E. ADDITIONAL EXAMINATION 1. X-Ray of Elbow (AP/Lat) Finding Picture can be seen on the last of this paper Conclusion: Fracture of Supracondyler Humeri Sinistra Gartland III 2. Laboratory Finding Hb : 9.9 g/dl Ht : 29 %

AL : 10200/uL AT : 332000/uL F. 2nd ASSESMENT Closed Fracture of Supracondyler Humeri Sinistra Gartland III with Medianus Nerve Deficit G. 2nd PLANNING a. Initial Treatment In ward (hospitalized) Novalgin syrup 3 x cth I Calcidin syrup 1 x cth I Long arm slab b. Operatif Pro Elective ORIF